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THE RED SECTION: HOW I APPROACH IT

Endoscopy in the Morbidly Obese: A Case Highlighting Healthcare Inequities

Bhalla, Sean MD1; Sonnenday, Christopher J. MD, MHS2; Schulman, Allison R. MD, MPH1,2

Author Information
The American Journal of Gastroenterology: February 2021 - Volume 116 - Issue 2 - p 229-233
doi: 10.14309/ajg.0000000000001081
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INTRODUCTION

Obesity continues to be a public health concern across the globe, with major implications for the health and well-being of the population. The World Health Organization estimates that 650 million people worldwide are obese (1), with an estimated 93 million people in the United States (2). From 1999–2000 through 2017–2018 (1), the prevalence of obesity increased from 30.5% to 42.4%, and the prevalence of severe obesity increased from 4.7% to 9.2% (Table 1, Figure 1) (2). It is projected that the prevalence of patients with a body mass index of greater than 35 kg/m2 will be 24% by 2030, which is roughly 1 of every 4 Americans (3). The current and future impacts of obesity on morbidity, mortality, and healthcare costs are profound.

Table 1.
Table 1.:
Review of body mass index (BMI) classification
Figure 1.
Figure 1.:
Trends in age-adjusted obesity and severe obesity prevalence among adults aged 20 years and older: United States, 1999–2000 through 2017–2018 (2). 1Significant linear trend. Notes: Estimates were age adjusted by the direct method to the 2000 US Census population using the age groups 20-39. 40-59. and 60 and over. Source: NCHS, National Health and Nutrition Examination Survey, 1999-2018. Figure reused from Ref. (2).

Providing optimal care for our patients with obesity can be challenging and fraught with obstacles. Stigma and discrimination toward obese persons in healthcare centers are pervasive and readily apparent from the hospital infrastructure, medical equipment, and preconceptions from healthcare professionals. In fact, patients with obesity are less likely to seek out care because of perceived and actual biases (4). For example, it has been shown that patients with obesity are less likely to undergo appropriate preventative care including cancer screening, counseling on tobacco cessation, and psychological referrals (5). Obesity is considered a sign of personal moral failure as opposed to a disease state (6), best exemplified by the inconsistent coverage of insurance companies for bariatric surgery.

Endoscopy poses unique challenges to the treatment of patients with obesity, bringing to light existing disparities within our healthcare system. The current coronavirus disease (COVID-19) pandemic has pushed our field to provide high-quality care in novel ways, forcing accelerated innovation and adaptation. Perhaps now is the time to consider redesigning clinical care delivery to overcome barriers to treatment, using this unprecedented opportunity to address disparities. This is particularly true, given recent evidence that obesity may predispose to severe illness in patients with COVID-19 (7). We present a case of a young man with morbid obesity that highlights many of these inequities and also provide a systematic framework to approach these challenges in the future.

CASE REPORT

A 29-year-old man with a history of severe obesity (body mass index of 92 kg/m2 and weight of 670 pounds) initially presented to a local hospital with severe epigastric abdominal pain and nonbloody emesis. Work-up was notable for an abnormal hepatic function panel including aspartate transaminase of 192, alanine aminotransferase of 214, alkaline phosphatase of 138, bilirubin of 1.8, and normal lipase of 40. He was deemed intermediate risk of choledocholithiasis.

Abdominal ultrasound demonstrated increased echogenicity of the liver and cholelithiasis (largest 8 mm), but could not visualize the common bile duct due to his body habitus. Magnetic resonance imaging, computed tomography, and hepatobiliary iminodiacetic acid scan machines were not able to accommodate his weight. Endoscopic ultrasound with addition of endoscopic retrograde cholangiopancreatography (ERCP) if choledocholithiasis was found was entertained, but the fluoroscopy table was unable to accommodate his weight. Given inability to offer standard of care management, the patient was treated conservatively with bowel rest.

However, on day 2 of admission, he developed significant worsening of pain. He was ultimately transferred to our tertiary care center and, on arrival, was noted to have pancreatitis with an elevated lipase of 1,526 and increasing liver function tests. An ERCP was planned, but could not be performed in the endoscopy unit given table restrictions of 400 pounds. Alternative locations were explored; however, the interventional radiology and cardiovascular suites had a weight limit of 500 pounds. Only 1 operating room could accommodate performing an ERCP for a patient of his size.

The plan for definitive management of his gallbladder was also reviewed. His candidacy for cholecystectomy through a laparoscopic or open surgical approach, and cholecystostomy tube through a percutaneous approach, was reviewed with our surgical and interventional radiology teams, respectively. He was deemed to be a high-risk candidate for all these interventions.

ERCP with potential cystic duct stent placement was pursued, but with several barriers. The patient was unable to be positioned optimally for ERCP (i.e., prone) given his size and concern for airway protection. The largest C-arm in the hospital could not be appropriately positioned over the patient's right upper quadrant due to his abdominal body habitus, limiting visualization of the entire biliary tree. The fluoroscopic imaging that was obtained was poor quality because of poor penetration through thick subcutaneous tissue (Figure 2a,b). The gastroscope could not reach across the bed over the patient, so endoscopy equipment was positioned behind the endoscopist leading to inability to easily manipulate the duodenoscope and a poor ergonomic set up. Choledocholithiasis was encountered, and 4 stones were removed; however, the mid cystic duct was completely occluded, negating the possibility of stenting, and leaving the patient without a viable option for definitive gallbladder management. Immediately after the procedure, the table collapsed with the patient in place, leading to considerable difficulty safely moving the patient to a portable bed.

Figure 2.
Figure 2.:
Fluoroscopic images during endoscopic retrograde cholangiopancreatography showing poor quality cholangiogram (a) and cystic duct take-off (b) given limited radiation penetration.

His clinical condition improved after ERCP. He was treated conservatively with antibiotics and ultimately discharged without standard of care management of his gallbladder disease.

ENDOSCOPY IN THE MORBIDLY OBESE

Obesity is a known independent risk factor for numerous gastrointestinal diseases, many of which require endoscopy for screening, diagnosis, surveillance, and/or treatment. However, endoscopy in patients with obesity poses unique challenges to management, exacerbating inequities within our healthcare system. For example, patients with obesity are at increased risk of developing colon cancer– and colon cancer–associated mortality (8), yet are known to undergo less screening colonoscopy (9). Obesity is also an independent risk factor for esophageal cancer, in addition to other pathology commonly necessitating upper endoscopic evaluation such as gastritis and hiatal hernias (10). Furthermore, conditions such as pancreatitis (11) and cholelithiasis (12) are more common in this patient population, escalating the need for advanced endoscopic procedures such as endoscopic ultrasound and ERCP. These procedures typically warrant preprocedure radiographic evaluation which, as the previous case exemplified, can be a challenge and further exacerbate existing disparities.

Despite the amplified need for endoscopic evaluation and intervention, there is scarce literature on the approach to endoscopy in the obese and morbidly obese and the challenges that may be encountered. The available data focus predominantly on the safety of administering sedation in this patient population during these procedures and suggest that obesity is an independent risk factor for sedation-related complications (13). Literature regarding challenges in performing endoscopy within the existing healthcare system, in regard to hospital infrastructure and medical equipment, is lacking. To provide a safe and systematic approach to endoscopy in this high-risk population, several important considerations including medical optimization, location selection, sedation planning, and necessary equipment, positioning, and monitoring for the procedure are outlined in Table 2. More data and guidance are needed in this challenging patient population.

Table 2.
Table 2.:
Approach to performing safe endoscopy in obese patients
Table 2-A.
Table 2-A.:
Approach to performing safe endoscopy in obese patients

CONCLUSION

The case presented here highlights several challenges we faced attempting to provide standard of care treatment for our patient with severe obesity and underscores the potential for substandard care in this high-risk population. Initial management of this patient's condition was delayed given inability to pursue the appropriate radiographic work-up and procedural interventions. He was instead treated conservatively and, only when his condition worsened, transferred to a tertiary care center for management. This delay in care may have potentiated the development of gallstone pancreatitis. Furthermore, despite being transferred to a tertiary care center, inadequate hospital infrastructure and ineffective medical equipment led to difficulty facilitating and ultimately performing the ERCP, respectively. Moreover, the patient was unable to undergo definitive therapy for cholelithiasis, leaving him at risk of future complications.

The COVID-19 pandemic has forced human innovation to adapt routine systems and drastically change our way of living in a short period of time. Furthermore, evidence is emerging regarding obesity as a risk factor for severe illness in patients with COVID-19 (7). This case should force us to consider redesigning clinical care delivery to overcome many of the aforementioned barriers to obesity treatment because this would otherwise be a missed opportunity to address this public health crisis. There is no time like the present to create an inclusive, sustainable healthcare system that will allow us to better serve all our patients.

CONFLICTS OF INTEREST

Guarantor of the article: Allison R. Schulman, MD, MPH.

Specific author contributions: S.B.: drafting manuscript. C.J.S.: editing manuscript. A.R.S.: drafting and editing manuscript.

Financial support: None to report.

Potential competing interests: S.B. and C.J.S. none. A. R.S.: Olympus—consultant, Apollo Endosurgery, Boston Scientific, and MicroTech—consultant; GI Dynamics—research/grant support.

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